Surgical mistakes persist in Bay State

Still a tiny fraction of total procedures

By Liz Kowalczyk, Globe Staff | October 26, 2007

During the past three years, doctors at Massachusetts hospitals mistakenly removed a patient's kidney when they were supposed to take out her gallbladder and performed an unscheduled cervical biopsy on a woman who had the same first name as the patient scheduled for the procedure.

They left two sponges inside a child's mouth after surgery, temporarily obstructing the patient's breathing, and they accidentally cut into wrong knees, kidneys, and fingers.

Despite more than a decade of efforts by hospitals and regulators to prevent such surgical errors, they remain a persistent problem. Hospitals reported 36 instances when doctors performed the wrong procedure or operated on the wrong site or wrong patient between January 2005 and last month, according to documents the Globe requested from the state Department of Public Health. There were 38 cases of sponges, surgical instruments, or other pieces of equipment left inside patients.

In most cases examined by the Globe, patients did not appear to suffer long-term physical harm, but many had to undergo second surgeries to correct problems while others experienced pain before objects were removed.

The number of errors are a tiny fraction of the thousands of surgeries and procedures performed annually, but patient safety specialists said that even the roughly 25 mistakes Massachusetts hospitals have reported each year since 2002 is too many. These types of mistakes are considered "never events," meaning they should never happen.

During the 1980s and 1990s, amid several high-profile wrong-site surgery cases, it became standard practice at hospitals nationwide to mark a patient's body at the correct incision site, verify the patient's name, and take "timeouts" before surgery to verify the correct procedure and site. Hospitals also required staff to start counting instruments and sponges before and after surgery, believing that would enable them to know when an object was missing and may have been left inside a patient.

Descriptions of incidents in the records show that these policies and procedures are not implemented consistently and that surgeons in particular sometimes don't follow them. Patient safety specialists said that nurses and technicians may be afraid to confront surgeons about lapses and that, because these errors happen infrequently, staff may feel it's not necessary to follow prevention strategies religiously.

"The culture piece is huge," said Diane Rydrych, assistant director of health policy for the Minnesota Department of Health. "Hierarchy is a huge presence in hospitals, especially in ORs. A surgeon can come in and say, 'I'm going to do it my way.' We have heard that very, very often. And hospital analyses reveal that someone knew something was wrong but didn't speak up."

Hospitals nationwide are struggling with this problem. Minnesota in 2003 became one of the first states to require hospitals to report publicly the occurrence of 27 types of never events. Of 154 error reports in the year that ended Oct. 6, 2006, 65 were for wrong-site surgery and objects left inside patients during operations. The number of these errors is rising in Minnesota, but that could be because hospitals are becoming more conscientious about reporting, not because more mistakes are occurring. Massachusetts requires hospitals to report serious incidents, but does not define them as specifically as Minnesota and does not report errors publicly.

The Joint Commission, a national organization that accredits hospitals, said new cases of wrong-site, wrong-procedure, and wrong-patient surgery are being reported at a rate of five to eight per month to its voluntary tracking system, an increasing rate. The organization held a summit on the issue in February, saying these are persistent problems that are not going away despite years of prevention efforts. The group recommended that professional societies promote prevention measures to doctors and that hospitals adopt "zero tolerance" policies for staff who deviate from timeouts and other strategies.

"What we're recognizing is that hospitals do not have the expertise to evaluate the problems and understand them well enough to create substantial and sustained" improvement, said Dr. Peter Angood, the Joint Commission's vice president and chief patient safety officer. "Healthcare has been based historically on knowledge of a disease. [People are] not trained how to function as teams, so we wind up with these persistent problems."

The causes of errors in the Massachusetts cases vary widely, including surgeons grabbing sponges to stop bleeding without telling the nurse tracking them; doctors making incisions before the timeout to verify the correct site; nurses forgetting to mark the correct incision site; and X-rays that were mislabeled as to the left and right side. In one case of a retained object at Newton-Wellesley Hospital last year, a sales representative was in the operating room and may have distracted nurses as they counted instruments and sponges, records show.

In some cases of retained objects, such as a drill bit or part of a stapler breaking off inside the patient, the problem was the equipment.

Overall, public health officials cited hospitals for violating patient safety rules in just 10 of the 74 cases, because most hospitals had already implemented improvement plans or the state determined that the doctor, not the hospital, was at fault.

At Cambridge Health Alliance's Somerville Hospital, two patients with the same first name were waiting in separate exam rooms in the gynecological clinic one day in November 2005. One patient needed a colposcopy, an examination of the vagina and cervix with a magnifying device, and a biopsy, and the other needed a routine, less-invasive checkup. A medical assistant accidentally switched the charts while hanging them outside each door.

The patient who mistakenly underwent the colposcopy did not object, Dr. Steven Schwaitzberg, chief of surgery, said in an interview, though she did not speak English and had an interpreter. He said the patient did not suffer physical harm, but he acknowledged that she could have been upset by the mistake.

At the time, he said, staff did not take timeouts before office procedures. Health officials cited the hospital for poor recordkeeping. Now a nurse and medical assistant must verify the patient's full name and the purpose of the visit before the doctor comes in, Schwaitzberg said.

At Milford Regional Medical Center in June, a surgeon removed the kidney of an 84-year-old woman instead of her gallbladder when he encountered extensive bleeding and swelling inside the patient that obscured his vision. Health officials did not cite the hospital because they believed the mistake was a result of surgeon error, not of poor hospital procedures, said Paul Dreyer, director of healthcare quality for the public health department. The Board of Registration in Medicine, which licenses doctors, disciplined the surgeon and now requires special monitoring of his surgeries because he also misread a test to confirm the patient's anatomy.

At Children's Hospital Boston in February, a patient who underwent oral surgery, developed labored breathing in the postanesthesia intensive care unit and did not improve despite various interventions. Several hours later, a surgical resident remembered that two sponges placed at the beginning of the operation hadn't been removed. They were taken out and the patient improved.

Dreyer said health officials did not cite the hospital because it had an improvement plan already in place before the investigation was concluded.

If a hospital has repeated instances of the same mistake, officials might issue a citation, called a "Statement of Deficiencies," even if it has an improvement plan. But most times, the underlying causes of the repeated mistakes are different, so no citation is issued, he said.

Hospitals are adopting new measures such as team training for operating room staff and bar-coding instruments and sponges so that a computer, not a person, keeps count of items going into patients and coming out. Dreyer said he believes public reporting of these errors - which the health department is planning as soon as next year - will help reduce errors because it will further increase the focus on prevention.

Even if patients don't suffer long-term injury, these errors cause major inconvenience and risk.

"Their trust is eroded in the healthcare system and they have to manage the psychological impact of 'why did this happen to me?' Then they have to trust enough to have the correct procedure done," Angood said.